31 January 2025 (Friday) - UKAS Update

The United Kingdon Accreditation Service sent their update today. You can read it by clicking here. Which is more than can be said for their standards. You have to pay good money to see those.

Am I being ridiculously reactionary in wondering that if they were more open about what their standards actually are, their quarterly newsletters might make more (any) sense?

30 January 2025 (Thursday) - Sysmex CellQuiz

Well, the answer was “severe burns”. I got it right, but bearing in mind I’ve seen precisely one Cabot ring in forty-four years of this game, would a better answer be “pretty much every malady known to medical science”?

I’m getting too old and too cynical for this game…

29 January 2025 (Wednesday) - e-learning

I did some refresher e-learning today.

Essentials of Patient Safety which was rather dull, and Information Governance which winds me up. In many ways information governance is so simple in theory. Just keep your trap shut and don't blab confidential information. In practice we hear about breaches all the time in newspapers which bend over backwards to highlight any such balls-ups. Clearly we need to be reminded of the need. Am I being hopelessly reactionary in thinking we shouldn’t be?

28 January 2025 (Tuesday) - Transfusiuon Evidence Library Update

The nice people at the Transfusion Evidence Alert overloaded me with their latest missive.

And again – tranexamic acid…

ARTICLES OF THE MONTH (Dec 2024 & Jan 2025) The effect of tranexamic acid on postpartum bleeding in women with moderate and severe anaemia (WOMAN-2): an international, randomised, double-blind, placebo-controlled trial. WOMAN-2 Trial Collaborators. (2024). Lancet. PICO Summary available Tranexamic acid versus placebo to prevent bleeding in patients with haematological malignancies and severe thrombocytopenia (TREATT): a randomised, double-blind, parallel, phase 3 superiority trial. TREATT Trial Investigators (2024). The Lancet. Haematology. PICO Summary available +++++

TOP ARTICLES Extracorporeal photopheresis for the prevention of rejection after lung transplantation - a prospective randomized controlled trial. Benazzo, A., et al. (2024). The European Respiratory Journal. Efficacy and safety of maintenance intravenous immunoglobulin in generalized myasthenia gravis patients with acetylcholine receptor antibodies: a multicenter, double-blind, placebo-controlled trial. Bril, V., et al. (2024). Muscle & Nerve. Anemia acuity effect on transfusion strategies in acute myocardial infarction: a secondary analysis of the MINT trial. Carrier, F. M., et al. (2024). JAMA Network Open. Restrictive versus liberal transfusion in myocardial infarction - a patient-level meta-analysis. Carson, J. L., et al. (2024). NEJM Evidence. Early high-dose cryoprecipitate to reduce mortality in adult patients with traumatic haemorrhage: the CRYOSTAT-2 RCT with cost-effectiveness analysis. Curry, N., et al. (2024). Health Technology Assessment. Cell salvage for the management of postpartum haemorrhage. Dey, T., et al. (2024). The Cochrane Database of Systematic Reviews. Viscoelastic haemostatic assays to guide therapy in elective surgery: an updated systematic review and meta-analysis. Dias, J. D., et al. (2024). Anaesthesia. Liberal or restrictive transfusion strategy in aneurysmal subarachnoid hemorrhage. English, S. W., et al. (2024). The New England Journal of Medicine. Traditional Chinese medicine FYTF-919 (Zhongfeng Xingnao oral prescription) for the treatment of acute intracerebral haemorrhage: a multicentre, randomised, placebo-controlled, double-blind, clinical trial. Guo, J., et al. (2024). Lancet. Single vs double-unit transfusion in patients with hematological disorders undergoing chemotherapy or stem cell transplantation: a systematic review and meta-analysis. Herrán-Fonseca, C., et al. (2024). Transfusion Medicine Reviews. [Record in progress]. Safety and efficacy of mitapivat in sickle cell disease (RISE UP): results from the phase 2 portion of a global, double-blind, randomised, placebo-controlled trial. I dowu, M., et al. (2024). The Lancet. Haematology. Treatment for women with postpartum iron deficiency anaemia. Jensen, M. C. H., et al. (2024). The Cochrane Database of Systematic Reviews. Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials. Ker, K., et al. (2024). Lancet. Postpartum maternal and infant haematological effects of second-trimester ferric carboxymaltose versus standard-of-care oral iron in Malawi: longitudinal follow-up of a randomised controlled trial. Mzembe, G., et al. (2024). The Lancet. Global Health. Effect and safety of intravenous iron compared to oral iron for treatment of iron deficiency anaemia in pregnancy. Nicholson, L., et al. (2024). The Cochrane Database of Systematic Reviews. Tranexamic acid for preventing postpartum haemorrhage after caesarean section. Rohwer, C., et al. (2024). The Cochrane Database of Systematic Reviews. Prognostic models for prediction of perioperative allogeneic red blood cell transfusion in adult cardiac surgery: a systematic review and meta-analysis. Van den Eynde, R., et al. (2024). Transfusion. [Record in progress]. Efficacy of restrictive versus liberal transfusion strategies in patients with traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials. Yuan, X., et al. (2024). Annals of Intensive Care.

26 January 2025 (Sunday) - Slide Saturday Challenge

The expert opinion said “The peripheral blood smear shows red blood cells with arrows pointing to echinocytes or burr cells. These have multiple, short, blunt projections evenly spaced over the cell surface. The central pallor is retained. These types of cells are seen in uremic patients or as an artifact of slide preparation (crenation effect).”

 

I’ll add the observation that those are echinocytes, NOT acanthocytes. I’ve mentioned those before.

21 January 2025 (Tuesday) - TTP

Here’s a rather good webinar on thrombotic thrombocytopenic purpura. Admittedly it does go on a bit, but something for nothing is never to be sniffed at.

 

20 January 2025 (Monday) - BTLP-TACT Exercise

Time for a BTLP-TACT exercise. If nothing else it might stem the seemingly constant stream of emails saying that I need to do more.

I was presented with two cases:

68407 – a forty-eight year-old woman having LSCS needing group and save.

She grouped as B Rh(D) Negative with a negative antibody screen.

 

49347 – an eighty-seven year-old woman having a hernia repair who also needed group and save.

She grouped as A Rh(D) Positive with a negative antibody screen.

 

I got it right,

19 January 2025 (Sunday) - Slide Saturday Challenge

Analyze this blood smear from #ASHImageBank, identify the large blue cell, and describe its roles in the body.

 

It’s a basophil a very granular mononuclear leukocyte. Basophils play a crucial role in the immune response by releasing histamine and heparin, which contribute to allergic reactions, inflammation, and defense again parasitic infections. They also help regulate blood flow and attract other immune cells to site of infection or injury.

16 January 2025 (Thursday) - BTLP-TACT Exercise

Well… I decided to have a go at the BTLP-TACT as I had a few minutes. It presented me with one case – a sixty year old chap in out patients with a DVT.

 

The blood group was positive in every well and was therefore uninterpretable. A job for NHSBT I think.

The antibody screen was positive in wells 1 and 3 so I performed antibody panels. The enzyme panel was negative in every cell, and the IAT panel was positive in cells 1, 3, 4, 6, 8 and 10 corresponding with anti-s but didn’t exclude anti-Kp(a)

 

I got the thumbs-up.

15 January 2025 (Wednesday) - Mobile Phones

The nice people at Lablogatory sent out their update today. This one was posed an interesting dilemma… Interesting in that is it actually a dilemma. The chap writing the article said “one thing I’d like to solve is the issue we see in the lab regarding the use of cell phones and other personal electronic devices. What options do we have as lab leaders?…”

 

Back in the day when I was a manager I was under strict orders that they were utterly and completely banned without question. The chap who gave me that order was always walking round fiddling on his mobile.

I found myself reflecting on the attitudes to mobile devices I’ve seen from managers over the years. Many are relaxed about them. Some would rather people didn’t have them in their pockets but see them as a necessary evil and a way of keeping people sweet. And others would quite happily let staff stand round idly chatting for up to half an hour but would go hysterical at the sight of a mobile phone.

 

The fellow writing the article then went on to say “you catch more flies with honey than with vinegar”. That was always my attitude, but I’m not a manager any more.

Personally I have my phone in my pocket all the time. If I get a message, my watch shows me a synopsis. Sometimes I need to deal with the message right away; other times not. Most people seem to do this these days. I don’t see this as an issue.

Am I wrong?

14 January 2025 (Tuesday) - Westgard QC Update

The nice people at Westgard QC sent out their update today. You can read it by clicking here.  

All rather dry and heavy going, but all useful stuff and in all honesty far more relevant to measuring things than much of the CPD that comes through these days…

13 January 2025 (Monday) - BTLP-TACT Exercise

Having found a mistake in the BTLP-TACT software I was loath to try again…

It presented me with one case – a ninety-seven year-old chap with liver disease who was bleeding.

He grouped as O Rh(D) Positive with a negative antibody screen

 

They’d asked for FFP. According to https://pmc.ncbi.nlm.nih.gov/articles/PMC8362012/ this is contraindicated. But the last time I didn’t issue, I got the thumbs down. So I issued. 

I was right to do so.

 

12 January 2025 (Sunday) - Slide Saturday Challenge

The American Society of Hematology had their Slide Saturday Challenge yesterday…

”Analyze this peripheral blood smear from the #ASHImageBank and identify the structures that the arrows are pointing to. How are these structures formed and what disorders could they be indicative of?

Share your insights in the comments!”

 

For once everyone had the answer right – acanthocytes. So often pictures like this on Facebook have as many disparate answers as there are people to give them.

 

The expert opinion said “The peripheral blood smear shows red blood cells with arrows pointing to acanthocytes (also called spur cells) which are spiculated cells with irregular, pointed or clublike projections that are unevenly distributed on the cell surface. Central pallor is absent.

Acanthocytes form as a result of membrane lipid abnormalities, and can be seen in liver disease, neuroacanthocytosis, severe malnutrition, and abetalipoproteinemia.

Did you guess correctly?”

 

Personally I’d have liked a comparison with burr cells; to me a burr cell has projections more regularly all the way round the cell. I would have liked to have seen if expert opinion agreed with me.

9 January 2025 (Thursday) - BTLP-TACT

Time for another BTLP-TACT exercise… I was presented with one case – a seventy-seven year-old woman requiring group and save.

 

The control was positive and in the past that has invalidated the entire group.

The antibody screen was positive in all three cells so I performed antibody panels.

The IAT panel was positive in all cells but 4 and 8 which could possibly have been a combination of D, E, Cw, S, Lu(a), K, Fy(a). However the enzyme screen was negative, so in BTLP-TACT world this would be a combination of anti-S and anti-Fy(a).

 

I got it wrong…

The combination of anti-S and anti-Fy(a) was correct but in BTLP-TACT world apparently anti-K might have been there too. I’m sure that in the past anti-K has had to work by enzyme in their exercises.

I shall add that to their list of foibiles…

 

But apparently anti-Jk(a) could not be excluded even though panel cell four had a negative reaction despite being Jk(a) positive.

In layman’s terms, that’s bollox.

6 January 2025 (Monday) - Fritsma Factor Update

The Fritsma Factor newsletter appeared in my inbox today. As always it is a rather useful update on all matters haemostatic…

5 January 2025 (Sunday) - Transfusion Dependent

So… a group & save comes in on a four-year-old child with a generic diagnosis on the accompanying form. I was rather busy so I just put the thing through the analyser. The analyser wasn’t having any of it, so as my son once told his primary school teacher, if you want a job done, do it yourself.

Given that the child had a historical blood group of O Rh(D) Negative I was rather surprised to see mixed field reactions with anti-A and with anti-D. Obviously I’d stuffed something up so I did it again and got the same result.

I then delved into the child’s history.

 

The child had thalassemia major. Having had in-utero transfusions before birth he was having regular transfusions every couple of months. Bearing in mind pedipacks are all O Rh(D) Negative that’s what he’d been getting, as do all small children needing transfusions. And having been started on O Rh(D) Negative, that’s what he stayed on.

 

It looks like the child is actually A Rh(D) Positive – there’s no anti-A reaction in the reverse group, and where else would the A Rh(D) Positive part of the mixed field reactions be coming from?

BUT… how can we determine the child’s actual group bearing in mind his condition means he will never be off of blood transfusions long enough for his own group to come through?

 

I posed this question on the Facebook Blood Bank Professionals Group. It was interesting how many people posted responses without actually reading what I’d actually written.

4 January 2025 (Saturday) - Back in the Day

I was having a bit of a clear-out at home today when I found my old notes and exam papers for my Special exam. Back in the day after achieving professional registration we would do the IBMS Special exam. Billed as MSc equivalent you couldn’t progress at all in our line of work without having passed the Special exam, and it had a reputation for being incredibly difficult. Pretty much everyone with whom I worked when I first started told me they had failed the exam several times.

The Special exam consisted of three written papers which together accounted for fifty per cent of the mark, and a practical project accounting for the other fifty per cent.

I passed it on the first attempt, and having passed it I wasn’t obliged to do any kind of professional updating of my knowledge and skills until CPD became mandatory some twenty years later.

Looking at the old papers I took has made me realise just how vital it is that dinosaurs like me do CPD…

 

Paper One

• A two-hour essay. Look at the options.Is there a need for change in how we are trained? Change was to be avoided at all costs!!
• “Side Room Testing” was the devil’s work and conjured up visions of nurses playing at science. No one dreamed of the likes of us doing near patient testing.
• The future revolutionizing what we do? Pah. We thought it would. In fact we now do far less tests and send everything interesting to specialist labs… who themselves don’t actually have that much of a variety in what they do either with everyone specializing in different things.
• “Clinical Budgeting” was a management catch-phrase of the mid 1980s which has long since been superceded by other equally well forgotten terms.

Paper Two

Two one-hour essays. Again look at the options.

• Vitamin B12 deficiency. Back in the day it was radio isotopes and the Schilling test. (You’ve never heard of it, have you!)
• Erythropoetin… blah on about that for an hour?
• Laboratory investigation of myelodysplastic syndromes? Yes – we used to do that. Gets sent away now.
• Complement… don’t get me started. Back then absolutely everything that science couldn’t explain was down to complement.
• Automated diffs – that was the future. Bear in mind this was only two years after the launch of the first analyser to do a five-part differential count.

 

Paper Three

Three forty minute essays.

• Safety and AIDS. Bear in mind that this was only four years after HIV had been discovered, and that I was told that in 1981 the average life expectancy of people in our line of work was fifty-seven. No one ever actually said that we used to die from that which we caught in the lab, but that was implied.
• Bleeding time… don’t laugh. We used to do them. We really did cut someone and time how long they bled for.
• Rouleaux and plasma cells… string that out for forty minutes.
• Heparin monitoring… anti-Xa assays were years into the future.
• LAP – that used to be an interesting test to do. Not done one for years.
• Red cell survival rather went the way of the Schilling test. There’s only so much radiation you can inject into people.

Project

I spent an age working up a way of identifying haemoglobinopathies by iso-electric focusing. Like everyone else doing the Special exam I put a lot of effort into devising a technique which would never actually be used.

 

It is pretty obvious that the future expected from the mid-eighties wasn’t the future that came forty years later.

2 January 2025 (Thursday) - Missing A Trick?

I can’t pretend that I’m really that happy with the most recent NEQAS morphology exercises. The trouble with blood film morphology is that for the most part you operate in isolation. So I had this vague idea that I might like to find some form of CPD whereby I get a blood film a day to look at which might give me immediate feedback . But I found this web site…

https://onedaytests.com/products/blood-film-analysis-and-differential-count

 It is offering blood film analysis (with a two-week turnaround time!) for three hundred and twenty-eight quid. Bearing in mind I can do fifty of these a day I think I’m missing a trick here…

2 January 2025 (Thursday) - NEQAS 2408BF

I got the results of NEQAS 2408BF today:
 
2408 BF1
 
I said:
 
Macrocytosis
Target cells (consensus 2^nd)
Nucleated red cells (consensus 1st)
Howell-Jolly bodies (consensus 3^rd)
Large platelets (consensus 6^th)
 
?? Marrow infiltration
 
Well… The patient has beta thalassaemia major with a previous splenectomy and was on a regular transfusion program (2 units every 4 weeks). The latter accounts for the normal red cells in the film, Got that wrong, didn’t I… Or did I.
I spotted the salient features, and how likely is it that we would get a sample from someone like this without a full history?
 
 
2408BF2
 
Macrocytosis
Basophilic stippling (consensus 6^th)
Echinocytes (consensus 7^th)
Target cells
Neutrophilia (consensus 3^rd)
 
And nrbc (consensus 1^st), polychromasia (consensus 4^th), anisopoik,
 
??? post splenectomy
 
Again, not brilliant, but again I spotted the salient features.

2 January 2025 (Thursday) - NEQAS 2404DF

I got the results of NEQAS 2404DF today:
 
Neut    37% (median 35.2% 2sd 23.3-47.0)
Lymph 50% (median 46.0% 2sd 29.7-62.3)
Mono  12% (median 11.2% 2sd   2.6-19.8)
Eos       1% (median  3.3% 2sd 0.0 – 7.7)
Baso     0% (median 1% 2sd 0.0-4.0)
 
I’m quite pleased with this… 

 

31 December 2024 (Tuesday) - Partial D

Our automated grouping machine didn’t like a particular sample and so I did a manual blood group. Look at that D rection. A D-group is positive, or it is not. And if the patient has had a blood transfusion from a donor of a differing D-group then there are two distinct populations of D-positive and D-negative cells.

That’s not what is happening here…

 

My initial reaction was that I’d stuffed the grouping up somehow and repeated it. And I got the same result…

 

A partial D reaction occurs when someone’s red cells have altered Rh(D) proteins (and therefore antigens) that react with some but not all anti-D typing reagents. And that looks like what has happened here.

There are many types of partial D, each with a unique genetic basis. Some people with partial D have weakly expressed D epitopes and are designated "partial weak D".

 

Blood Bank Guy’s take on the matter

A PhD submission on the topic

And another reference

 

Interestingly these references hint that partial D happens in about 1% of the population… Having a degree in maths (which I have) and knowing our workload (which I do) I should be seeing cases like this many times a month.

But I don’t.

Presumably the anti-D we use picks up the more common variants and only has issues with the more obscure ones?

I am looking forward to see what NHSBT have to say about this one.